NeutraSal — United Healthcare

Initial criteria

• EITHER (Diagnosis of xerostomia AND History of failure or contraindication to both of the following: saliva stimulants (e.g. sugar-free hard candies or gum) AND two OTC saliva substitutes (e.g. Biotene, Mouth Kote, Oasis, SalivaSure, Salivea); document name and duration of trial)
• OR (Diagnosis of oral mucositis AND History of failure or contraindication to both of the following: topical lidocaine AND salt and sodium bicarbonate rinse)

Reauthorization criteria

• Documentation of a positive response to therapy

Approval duration

12 months